Journal List > J Korean Endocr Soc > v.22(1) > 1003403

TOOLS
Park, Jung, Ju, Kim, Yoon, Seo, Kim, and Park: p-ANCA Positive Vasculitis after Propylthiouracil (PTU) Medication in a Patient with Graves' Disease
Case Report
Journal of Korean Endocrine Society

Journal of Korean Endocrine Society 2007; 22(1): 45-49.

Published online: 20 February 2007

DOI: https://doi.org/10.3803/jkes.2007.22.1.45

p-ANCA Positive Vasculitis after Propylthiouracil (PTU) Medication in a Patient with Graves' Disease

Chan-Kwon Park, Yun-Hwa Jung, Ji-Hyeon Ju, Hyun-Sook Kim, Chong-Hyeon Yoon, Young-Il Seo1, Ho-Youn Kim, Sung-Hwan Park

Kangnam St. Mary's hospital, Division of Rheumatology, Department of Internal Medicine, The Catholic University of Korea and Sacred Heart hospital, Korea.

1Division of Rheumatology, Department of Internal Medicine, Hallym University, Korea.

Received 17 June 2006       Accepted 21 July 2006

Copyright © 2007 Korean Endocrine Society

Abstract

A 34-year old woman was admitted to our hospital complaining of fever and multiple palpable purpura. She presented with symmetrical, polymorphic, dark-violet and black colored, edematous, tender, necrotic ulcerations and palpable purpuric lesions on her upper and lower extremities and face, except for her trunk, after restarting PTU therapy for relapsing Graves' disease. Palpable purpura can have many causes, including infectious and autoimmune processes. A rare cause is drug-induced vasculitis, and this may result from the production of antineutrophil cytoplasmic antibodies (ANCAs) in response to a medication. The patient's PTU-induced vasculitis was diagnosed by skin biopsy, and biopsy displayed remarkable p-ANCA positivity. The skin lesions resolved immediately after discontinuation of the drug and steroid therapy. We report here on a case of PTU induced vasculitis in a woman with Graves' disease who presented with palpable purpuric lesions and myeloperoxidase ANCA positivity in the blood. We observed clinical resolution of her symptoms following withdrawal of the PTU.

Keywords: Antineutrophil cytoplasmic antibody (ANCA), Graves' disease, PTU-induced vasculitis

Figures and Tables

Fig. 1
Skin biopsy section showed hemorrhage, thrombi formation, findings of vasculitis, acute and chronic inflammation in the dermis and fibrinoid necrosis, RBC extravasation, and thrombi formation. (A: H&E. ×40, B: H&E. ×400)
jkes-22-45-g001
Table 1
PTU-induced vasculitis with major organ involvement in Korea
jkes-22-45-i001

References

1. Jacobs EM, Hartkamp A, Kaasjager HA. PTU-associated cutaneous vasculitis with ANCA anti-MPO and anti-PR3 antibodies. Neth J Med. 2003. 61:296–299.
2. DeGroot LJ, Jameson JL, Kretser D. Endocrinology. 2006. 5th ed. Saunders;2009–2010.
3. Gunton JE, Stiel J, Clifton-Bligh P, Wilmshurst E, McElduff A. Prevalence of positive anti-neutrophil cytoplasmic antibody (ANCA) in patients receiving anti-thyroid medication. Eur J Endocrinol. 2000. 142:587.
4. Lam DC, Lindsay RH. Accumulation of 2-14 Cpropylthiouracil in human polymorphonuclear leukocytes. Biochem Pharmacol. 1979. 28:2289–2296.
5. Jiang X, Khursigara G, Rubin RL. Transformation of lupus inducing drugs to cytotoxic products by activated neutrophils. Science. 1994. 266:810–813.
6. Wolf D, Ben-Yehuda A, Okon E, Naparstek Y. Nodular vasculitis associated with propylthiouracil therapy. Cutis. 1992. 49:253–255.
7. Choi HK, Merkel PA, Tervaert JW, Black RM, McCluskey RT, Niles JL. Alternating antineutrophil cytoplasmic antibody specificity: drug-induced vasculitis in a patient with Wegeners granulomatosis. Arthritis Rheum. 1999. 42:384–388.
8. Noh JY, Asari T, Hamada N, Makino F, Ishikawa N, Abe Y, Ito K. Frequency of appearance of myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA) in Graves' disease patients treated with propylthiouracil and the relationship between MPO-ANCA and clinical manifestations. Clin Endocrinol. 2001. 54:651–654.
9. Khurshid I, Sher J. Disseminated intravascular coagulation and vasculitis during propylthiouracil therapy. Postgrad Med J. 2000. 76:185–186.
10. Harper L, Cockwell P, Savage CO. Case of propylthiouracil-induced ANCA associated small vessel vasculitis. Nephrol Dial Transplant. 1998. 13:455–458.
11. Chastain MA, Russo GG, Boh EE, Chastain JB, Falabella A, Millikan LE. Propylthiouracil hypersensitivity: report of two patients with vasculitis and review of the literature. J Am Acad Dermatol. 1999. 41:757–764.
12. Lee JC, Yoo B, Lim YJ, Kim SH, Lim M, Cho YS, Shong YK, Moon HB. A case of propylthiouracil-induced lupus. J Korean Rheum Assoc. 1999. 6:75–78.
13. Rhee Y, Chung SS, Nam SY, Song YD, Lim SK, Kim KR, Lee HC, Huh KB. A case of propylthiouracil induced anti-neutrophil cytoplasmic antibody (ANCA) positive vasculitis. J Korean Soc Endocrinol. 1999. 14:757–763.
14. Park YK, Yun YW, Sung SS, Park US, Park SH, Woo JH, Park JI, Jang SJ, Han SW, Oh YH, Park YW, Park MH, Kim HJ. Propylthiouracil-associated p-ANCA positive vasculitis with focal segmental glomerulosclerosis. Korean J Nephrol. 2004. 23:997–1003.
15. Kim JH, Kim HW, Jang EC, Jung WR, Ko SH, Shin YS, Park CW, Song KH, Choi YJ, Chang YS, Bang BK. A case of ANCA-positive crescentic glomerulonephritis after propylthiouracil treatment in Graves' disease. Korean J Nephrol. 2005. 24:305–312.
16. Lee SY, Jung JY, Lee KJ, Lee SH, Kim SJ, Lee EJ, Hur GY, Jung HC, Kim JH, Shin C, Shim JJ, In KH, Kang KH, Yoo SH. A case of propylthiouracil induced diffuse pulmonary hemorrhage. Tuberc Respir Dis. 2005. 58:78–82.
17. Kim JW, Kim JS. A case of propylthiouracil-induced lupus erythematosus accompanied by antineutrophil cytoplasmic antibody-positive vasculitis. Korean J Dermatol. 2005. 43:496–500.
TOOLS
Similar articles